To circlage or not to circlage, that was the question

A year ago today Steve dropped the girls off with some friends for a day-long play date and came in to the hospital to be with me.   He didn't bring a camera.  It was June 30, 2012.

The night before we had been told about a circlage.  It is a stitch that, like purse strings, would close the open cervix.  We'd been given the option to do one or not to do one.  The doctor explained the risk.  The circlage may go wrong.   The prolapsing membranes, or the "sticking out of the baby's sac beyond the cervix," complicated things.  By putting in the circlage, accidental rupture of the membranes could occur.  My water could break, possibly introducing infection or leading to uncontrollable labor.  We could lose the baby.

He told us it was up to us to decide how to proceed.

Steve is an economist, which also means he is a statistician.  He works with numbers (especially the kind that look like greek letters) professionally.  "Is there a study that looks at this sort of thing that we could read?" he asked, "We could use some more information.  What are we looking at here?"  The doctor explained that each journey is a bit different, that there weren't any promises, that this was a hard case -- it was hard to know what was best for the baby and the mom.

An hour later he came back with a study of women who also had prolapsing membranes.  Half were treated with bedrest alone, half were given a circlage and indomethacin (a drug).  It was this study.  The sample set was small, but we poured over a graph and the numbers.  In the case of bedrest only, the mean amount of days gained was 20.  In the case of the circlage group, the babies gained a mean of 54 days.  But the bar graph of each individual participant in the study is what tipped the scale.  In the bed rest alone bar graph, we saw we might gain two to three weeks -- like the mean suggested -- but that didn't get us to an age of viability, and even if it did, all the bedrest-only babies were born prematurely.  With a circlage, a few babies were born in that first month, but then if they made it past the first month, many -- seven out of thirteen -- made it to full term.  A full term baby.  Oh, how I wanted that. This was his chance.

The doctor let us sleep on it, and when he came in for rounds that morning a year ago today, we notified him of our choice.  He told us we could have another day if we wanted, to think some more.  We said we were certain, a circlage it would be, and we'd prefer not waiting another day.  We wanted this risky proceedure behind us, and I didn't want to risk going back into labor. When it was done, we'd have a clearer sense of what the murky future might be, and we could step off this narrow fence between life and death.  For a time, at least.

But Steve didn't bring our camera.  "You have to have it," I said.   He didn't want to leave my side. "You must get a camera."  I said, "Maybe they have a disposable one in the gift store."

I might be meeting my 12 oz baby today, and I wanted a camera to take his picture.  If I wasn't going to know him, if I was going to have to say goodbye, I wanted to document every minute of his life so I could remember.  There wouldn't be that many minutes if the circlage went wrong.

While he was gone, I started doing some research on the computer he'd brought with him that morning. (Why had he not brought a camera?)  The nurse walked in.

"I wouldn't do too much research on a circlage" she said.

I am sure she didn't want me to talk myself out of it because one person somewhere in the world had had a bad experience, or because the images looked scary or something.  But we were firm in our decision, so that wasn't an issue.  Besides, that wasn't why the computer was out.

"I'm not researching that," I said.  "We don't have a name for our son.  I'm trying to find a good one.  If we're only going to know him for a few minutes, I want to be able to call him by name."

This time I did cry in front of a nurse.  I didn't mean to, but it just came out.

We thought about calling him William, after one of Steve's favorite grandpa, Grandpa Bill.  But Grandpa Bill had passed away recently, and we didn't want to lose two Williams back-to-back. We ran into a lot of that.  What do we call him?  What name honors him, regardless of how long or short his life is?  If he's born today, he will not live.  What if we then had another boy? 

We came up with a name moments before the circlage was placed, but I can't now remember what it was.  Maybe it was Samuel?  It doesn't matter, though. We ended up not needing a name that day.

By this point, our friends and family all knew what was happening.  Prayers were pouring in.  Thank you, friends.  I had to delete one update, because Steve worried it was a little too detailed, but the point of it all got out there anyway.  We were fighting for our son's life, and wanted prayer.  So prayer we got.  That meant the world to me.  I knew that we weren't alone, no matter the outcome.

The doctor decided to use general anesthetic instead of local. He explained that he wanted me as still as possible so that he could work with the prolapsing membranes. I appreciated that.

An anesthesiologist in the pre-op room -- not my anesthesiologist, but just one of the other ones hanging out -- declared loudly prior to the procedure that he couldn't believe they were putting me under general, that the best practice was local, that if he were in charge of my case, he wouldn't be using local.

I was grateful for my anesthesiologist, who clearly had a better relationship with the high risk pregnancy doctor, and who understood that sometimes "best practices" don't apply. I wished the other anesthesiologist would keep his opinions to himself.  No sense scaring the patient. That was me, I was the patient. I wasn't  in the mood to be scared or second-guess my doctor.

And frankly, I didn't want to be awake.  I wanted this procedure to be over, and I wanted to know we were all okay -- or not -- but I didn't want to know what was unfolding when I had no control over it and my only option was to stay as still as possible. I trusted them, and I knew this was our best shot.

Before we went in to have the surgery done, the doctor told me, "I only know what we saw most recently. If I get in there, and things are different, and I don't think I can place this circlage safely, you will wake up and nothing will have been done. I am going to be as careful as I can."

"Thank you," I said, "and thank you in advance for trying."

What felt like only a few minutes later, I woke up. I felt the stitches. I was dry. It was done.  Before the doctor said a thing, I knew where we were. I sighed in relief as the doctor said,  "The circlage was placed successfully."

I went back up to the high risk pregnancy floor with my husband. I had spend the morning sending instant messages to a girlfriend who had had a circlage placed early in the second trimester and carried her baby to term. Suddenly this was a new possibility. She sent me an instant message that evening. "Glad to hear your membranes did not rupture. The worst danger should be over now and it should be smooth and bored sailing I hope until 37 weeks."

I agreed. She was right. We had a good chance now, I thought.

"You just have to make it three weeks until he is viable and five until he will likely have no long term complications. You can totally do it. If the circlage does its job you will go to term.  I am so happy for you.  I was worrying all day."

This was just the pep talk I needed. Three to five more weeks.  I could do that, right? Yes, this was my first goal - three weeks, 24 weeks gestation. Then 28 weeks. Then 34, then 37. Each number meant a better life, greater chances. We could get there.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

June 30, 2013  Two weeks and three days from now is my son's first birthday. We didn't make it three to five more weeks, but we DID make it.  Praise God, who knits most of us in our mother's womb, but knit Jonathan together half inside and half outside the womb, with skilled physicians and nurses as his hands in the process.

We met a new family at church today and decided on a spontaneous backyard picnic.  The weather was perfect, and Jonathan spent most of the time on a blanket in the shade of an oak tree laughing and grabbing his toy lion rattle.  He has started to enjoy the out-of-doors. He smiles.  A lot.  We are grateful you spent as much time in as you did, buddy.  We are glad you can be outside now.

When night fell

June 29 into June 30, 2012

A year ago at this time I stared at the white ceiling, then at the cabinets around my bed.  A horrid shade of light pink shelving.  My eyes then whirred around and caught light reflecting on the window. After watching the hues of the brick building next to mine shift and darken, I stared back up at the ceiling.

I was alone in the hospital.

My husband had gone home and put the kids to bed and the nurses wouldn't need to monitor contractions for several hours or until I felt them again myself. They'd stopped for now, so all was still. I could stop trying to be strong, stop trying to seem rational and put together about all this.  I didn't need to gather information anymore or even hold a conversation. In short, I could cry.

But I didn't. Not right away. My brain was still whirring.

How did I get here?  Was this the beginning of the end of this pregnancy, the end of this half pound being in my belly? Was this a death?  It would have been, it could have been.  If I had stayed at work and then gone home and had the picnic, ignored the barely perceptible contractions -- what then?  I knew what then. I'd read the tear-filled posts by other moms on the board for incompetent cervices. But that was not my path. Why wasn't it my path? And now? Now that I'm here, what now?

The doctor had talked about a circlage, but said that in cases of prolapsing membranes, a circlage was risky. He also said that it might not be an incompetent cervix. I wasn't very effaced, as is usual for incompetent cervices. And if it wasn't my cervix, it was labor. And tying my cervix shut wouldn't stop that long term.

But I wanted to fix this. I wanted the hospital to find a way to keep him in. Because if we didn't... if I didn't do anything, what then?

He would be born, but he would not live. Could it be a death if the baby wasn't viable? It would hurt us as if it were a death. My family would rally around us. They'd understand our grief.  But it wouldn't be a baby, would it?  Not officially. Probably no funeral. No. I'd have a funeral. No. I didn't want this being to die.

My eyes fixated on a point on the ceiling, a tile just above the bed, turning grey as the late summer dusk called in the night.

I didn't want him to die.

I started crying. And praying. Then sobbing.

"God, this child is yours. He's always been yours. I can't hold him anymore. Please, hold him.  He's yours. Protect him. Please take him. I can't. My body isn't carrying him well any more. Please take him, hold him."

Realizing how "please take him" could sound, but not wanting to be too presumptuous, in an even quieter, stiller voice, my soul, like the voice of a timid child, cried, "please, don't let him die. Don't take him back. You gave him to us. Please don't take him back. Not yet."

---------------

At some point all parents realize that their children aren't really "theirs."  I had to face that fact early with my son.  In the middle of the night, on a hospital bed, only days away from the day he'd be born.

-------------------

Sorrow turned to anger and then back again to sorrow.  In the still of the now fully descended night, I fought with God. I cried and I sobbed. I pleaded and I prayed. This wasn't right. I was grateful to be here, yes, to still have a chance for this baby, yes, but I was losing so much. I might even be losing him. I was on strict bedrest now. Probably for five months. What about work?  My summer fun with my kids? The beach. My pregnancy swimsuit that I'd only worn once so far.  My marriage. Gardening. This baby. Mostly this baby. I thought I'd gotten over that miscarriage hump.  I'd thought he was a sure thing now. Healthy and strong, heart beating well. I'd thought he was ours.

I wrestled.  I mourned. I wanted some answers or peace, something that said everything would be okay.

And then I got it.  Not an answer, but a response nonetheless. "I am here."

That was it. No assurances, no peek into the future. Just "I am here."

But that was enough.

"Thank you." I replied.  A few more tears came.

Salt on my cheeks, I closed my eyes and tried to sleep.

~~~~~~~~~~~~~~~

6/29/13 -  Today my baby Jonathan sat up for the first time that sort of counted.  I mean to say he stayed seated for more than ten seconds without me holding him.  Up until now the record has been three seconds. He giggled with the girls who read him a book on the floor.  He's still a little tender and more prone to crying than usual, hang overs from Wednesday's surgery, but for the most part that seems behind him and he's so happy.

He fed himself applesauce for lunch. THAT was a mess, but he was very pleased with his accomplishment. He'll be one next month.

The day things went wrong

My nearly year-old Jonathan sits in the bassinet near my computer, fascinating with his hands and toys, experimenting with his voice, and feeling so much better.  Wednesday's surgery went well. We were out of the hospital three hours after surgery.  No complications this time, either.  We are so glad.

June 29, 2012
A year ago today, June 29, 2012, is when the unexpected happened.

I had prior approval to work a half-day.  I figured jet lag would start to kick in and I'd not have a full day of work in me.  So I slept in, had a nice morning with my girls, and then headed off to work.  I could have walked, but I was lazy, so I drove the mile instead.  As I walked the shaded path from the parking lot to the office, I breathed deeply.  Yes, good to be back.

I had two, maybe three braxton hicks contractions on my walk in.  One of them felt a little crampy.  It happened as I walked under the ancient oak tree.  I paused for a split second.  Ah, the fun of having my particular body.  The braxton hicks contractions had started early with Mimi, too.  It's just the way my body does pregnancy.

"Oh good!" I said as I walked in the office, "you two have met!"  I gave my friends a hug.  Elizabeth and Christina were both Medievalists.  Elizabeth was a friend from my husband's graduate school days. Christina was a work colleague. Elizabeth was in town, up from the South, for a conference, and I had told them they had to meet during her one month stay in the North. And there they were, both in my office chatting away like old friends.

"Welcome back!" they said.

I booted up my computer, leaned back in my chair, and started to catch up while I waited for the virus scan to finish its work. Elizabeth and I began to make plans for a back yard picnic that weekend so that our families could hang out.  Her oldest was (and not entirely by coincidence) nine months older than our oldest.  Their youngest and our youngest were also close in age.

Two more contractions snuck in.

After catching up with Christina, she left and I grabbed a glass of water.

The next time my belly tightened. I stopped typing and turned around and looked at Elizabeth, who was borrowing the other desk.

I didn't say anything, I just gave her a funny look.  But she knows me.

"Don't scare me," Elizabeth said.

"Maybe I should just put in a call to my doctor," I said.

"How long have you been having them?"

"Since before I gave you a hug hello.  But they're just braxton hicks."

"Might as well call."

----

I called my doctor's office and left a message, I really wasn't worried, just trying to be safe.

Elizabeth left and I continued working through my work emails.

Twenty minutes later they called back.  "The doctor says that as long as you're not having more than six an hour, she's not concerned.  We got your message yesterday, too, and that's fine."

"I'm having eight to ten contractions an hour" I said, "and one or two of them were kind of crampy."

"Just a moment" the nurse responded.

"I just talked to your doctor," she said after a pause, "Perhaps you should go in, to have it checked out."

"Sounds good," I said.  It's a Friday, let's just be sure things are all good before the weekend. The cramps were stronger than braxton-hicks, sort of, but they were really quite weak. A little different, maybe, but barely that.

I called Steve to let him know what was happening. "I can go by myself," I said, "No sense in trying to figure out child care.  I'm just going in to get it checked out. I should be home around dinner time."  Then I paused. Four to six hours.That was about right. Hospitals were slow if you weren't in actual labor.

"I'm coming home to get my kindle, so I have something to read while I wait."

I got the kindle as a graduation gift the month before.  I marveled at how it fit perfectly into the funky cut sleeves on the master's robe.  "The sleeves used to be for carrying books in the medieval age" I had declared (I'm actually not sure if that's true, you'd think with a handful of Medievalists as my closest friends I'd know.  It sounded right, though), "Now they're too skinny for books, but they fit kindles and cell phones just fine!

Steve brought me out my kindle as I drove up the driveway.  He'd taken the first half of the day to work, with the intent to nap with the kids in the afternoon. The girls were already in bed.  He gave me the Kindle and a hug, and a look that said, "oh, here we go again," while actually saying, "see you at five."

"Oh, one more thing," I said, "Elizabeth and her family might be coming over for dinner.  She was going to talk to Matt about it.  I'm sure they'll understand if we have to be flexible with time. And if you don't think you can get the back yard ready, then maybe we can hang out with them tomorrow night instead."

When I got to the ER, I was shown where to wait for the escort service to maternity. I stood for a while in that section of the lobby, back against the wall, waiting for the escort service. After a few minutes I grabbed a seat on the floor next to a woman who was actually in labor and who was also waiting to be escorted up. The front desk folks told me I could sit in a wheelchair, but that was on the other side of the room, and I felt silly sitting when I didn't even look pregnant, so I waved off their offer. Someone then wheeled me over a chair, and then I felt obliged (albeit still silly) to sit in it.

A moment later the escort person walked through the doors. So did another pregnant lady. That lady was REALLY REALLY in labor. "I'm 35 weeks along" she said. She looked panicked and in pain. Unlike the woman next to me who paused every few minutes and concentrated through her pain, this person was a panting, screaming mess.

The escort looked at a loss. Three wheelchairs, one person. The last one in line should not be left in the waiting room.

"I'll take one" I said, "I'm not probably in labor anyway, just have to have it checked out." As we went up the elevators, me pushing the relatively calm woman, I remarked, "My baby won't be born for another four months or so."

I got hooked up to the monitors to hear the baby's heart rate and measure contractions. They didn't really record the contractions that well, they were still tiny blips on the screen. Someone came in and checked me.  "Cervix is closed," she said, "but I want to do an ultrasound just to be sure all is well."

A chance to see my baby might make this whole false alarm worth it.

The ultrasound tech asked for my history, I told her about how my body "always did this" thing with fake contractions in the second trimester, and then I took a peek at my beautiful boy.  Cute kid. Sucking his finger. Nice heart beat. Cervix still closed, I could see that much. "So, everything looks good, then, right?"

"The doctor needs to read these images, I just do the scan" she said, as she continued to click and measure distances on the screen.

I'd never heard a tech say that before. I knew it was true, but normally they said, "The doc will look at this, but things are looking good so far."

So when I got back to the room, I used my phone to do a web search for an image of a cervix. Turns out that on an ultrasound they should look like long straight lines, not v-shaped.

Hm.

I found an image of a cervix that looked like mine had looked and read the words "funneling."

This was new.

---

Instead of hosting Elizabeth's family that night, Elizabeth's family hosted my daughters. They had a small college apartment near campus and agreed to let our girls hang out with theirs so that Steve could come in. He got a ride from friends to the hospital, since we only had the car I drove in. We think Matt, Elizabeth's husband, drove him in, but we really can't remember much. Just that he showed up soon after I called, we found a way for the girls to be taken care of, and we were both a little shocked.

I was admitted to the high risk pregnancy floor and another ultrasound was done around dinner time. This time the image was clear. I was two centimeters dilated with prolapsing membranes. This wasn't a v-shape any more, it was a straight shoot. And prolapsing membranes means that the sac holding my baby was pushing through that straight shoot.  All that sat between my baby's foot and the world was a thin sac.

How did I get here?

The words "incompetent cervix" was thrown about, as were the words "preterm labor."

"It could be either" the doctor had said. Then he talked about different treatment options. But the option right now was to try to control things, see if the situation "presented itself."  See what the next 24 hours held.

"If we can control the contractions, we can talk about other ways to keep this pregnancy going." the doctor said.

"How big is my baby now?" I asked the nurse. "Somewhere between a half and 3/4 pound." she said.  Steve and I laughed nervously.  So small.

"Grow, baby, grow."  We were a day shy of 21 weeks.  Or three days shy if you went by ultrasound measurements.  We had over three weeks to go before the magic 24 week mark -- the day he'd be considered viable.

----

That night Steve went home and I read posts on a support group for women with incompetent cervices.  Most had lost their first pregnancy, around 18 to 20 weeks, sometimes after having painless contractions. They were now on their second or third pregnancy and planning to have shots and circlages (like the ropes on a purse string, holding the cervix together), and other interventions to keep the baby in.

But they'd lost a child first, before they'd known there was a problem.

I was still pregnant.  And before bedtime hit, I was stable. I would stay pregnant, for another day at least.

How was I here?

I stared up at the ceiling of my empty room.  

How am I here?